Healthcare CDC Referral Form

Healthcare CDC Referral Form

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other Unknown

Referring Provider / Facility

Provider Contact Phone:    Fax:

Clinical Information & Reason for Referral

Symptom Onset Date:    Hospitalized: Yes No

Laboratory / Specimen Information

Specimen Type:    Collection Date:

Public Health Risk & Exposure History

Recent Travel (past 30 days):

Known Exposure to Confirmed Case: Yes No Unknown

Immunization & Pregnancy Status

Immunizations (relevant):

Pregnancy Status: Pregnant Not pregnant Unknown

Insurance Information (if applicable)

Policy Number:    Group Number:

Requested Public Health Action

Requested Assistance (check all that apply): Epidemiologic investigation and contact tracing Laboratory testing / reference confirmation Clinical/public health consultation Other (specify below)

Authorization to Disclose Protected Health Information

By signing below, I authorize the release of medical and public health information related to the above-named patient to authorized public health authorities, including federal public health personnel and laboratories, for the purpose of public health surveillance, outbreak response, disease control, case investigation, and necessary laboratory testing. This information may include diagnoses, laboratory results, treatment summaries, immunization records, and contact information of the patient and relevant contacts.

This authorization is voluntary. I understand that information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected under certain privacy laws; however, recipients are expected to maintain confidentiality in accordance with applicable law. I have the right to revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. Unless revoked earlier, this authorization will expire on the date specified below or one year from the date of signature if no expiration date is provided.

I certify that the information provided in this referral is true and accurate to the best of my knowledge and that I am authorized to provide this information and to request public health assistance.

Acknowledgment of Privacy Notice

I acknowledge that I have received and/or been offered a copy of the applicable privacy notice describing how health information about me may be used and disclosed, and my rights regarding such information.

Acknowledgment: I acknowledge receipt of the privacy notice I decline to acknowledge receipt

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